WHO partnership working group meeting Edinburgh, United Kingdom (Scotland)

27−29 March 2011

ABSTRACT

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Contents

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Introduction and context ......................................................................................... 1 Item 1. Health 2020: the new WHO European health strategy ............................... 2 Item 2. European noncommunicable diseases action plan..................................... 6 Item 3. Open session............................................................................................ 10 Item 4. EU 2020.................................................................................................... 11 Item 5. Collaborating centres’ and partners’ main activities, opportunities and challenges ............................................................................................................ 13 Item 6. Agreed action points ................................................................................. 21 Annex 1. List of participants.................................................................................. 22 Annex 2. Summary of ideas for collaboration on the NCD action plan ................. 26 

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Introduction and context WHO collaborating centres1 are designated by the WHO Director-General to carry out activities in support of WHO’s programmes. Currently, there are over 800 collaborating centres in more than 80 Member States working with WHO in areas such as health promotion, occupational health, communicable diseases, nutrition, mental health, chronic diseases and health technologies. This partnership meeting, the idea for which was first discussed some time ago, provided an opportunity for collaborating centres and partners2 in the WHO European Region who have a focus on health promotion, public health and the social determinants of health to network with each other. It also allowed representatives from WHO and EuroHealthNet to describe essential areas of current work with a view to identifying how collaborating centres and partners can contribute. It was the first such meeting of collaborating centres and partners for many years. It was convened at a pivotal time for the European Region, with the development of key initiatives such as the Health 2020 strategy and the noncommunicable diseases action plan. These initiatives are being progressed against a backdrop of important work that is being taken forward in Europe in relation to social determinants of health and the health divide, the implementation of a public health framework for action and the European Union (EU) 2020 programme which, while not focusing specifically on health, will nevertheless have a significant impact on health as it develops. In addition, the Region faces significant social and political challenges in the face of the worldwide recession that seem certain to have impacts on the health of populations over the coming decade. For health agencies, this raises not only challenges, but also opportunities. When NHS Health Scotland WHO collaborating centre for health promotion and public health development approached WHO Regional Office for Europe and suggested the meeting be convened, Regional Office eagerly agreed. Regional Office wishes to thank NHS Health Scotland for hosting the meeting and looks forward to further such meetings being hosted by other collaborating centres and partners in future. David L Pattison Head of International Development, NHS Health Scotland, United Kingdom Vivian Barnekow Programme Manager, Child and Adolescent Health Development, WHO Regional Office for Europe

1 For further information, see: http://www.who.int/collaboratingcentres/en/ 2 A list of participants is shown at Annex 1.

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Item 1. Health 2020: the new WHO European health strategy Briefing: Chris Brown, WHO Regional Office for Europe3 Average health has improved across Europe, there has been progress in advancing issue-specific health strategies and policies, and awareness of health as productive capital is increasing. However, Europe is entering a new era. The drivers that shape health and the determinants of health inequities are increasingly complex and interconnected, and the idea of health as a human right, as a public good and as an asset for development is facing ongoing and new challenges. For these reasons, a new approach to health governance is required for the 21st century. The health goals of Health 2020 are to:

reduce inequities in health by reducing differentials in opportunity to be healthy, risk of illness, consequences of ill health and premature death; and

increase the number of years spent in good health (healthy life years). This will involve an approach that tackles major drivers of change that affect health, social determinants of health and specific health issues. The health governance goals of Health 2020 are to:

ensure health and health equity are considered in decisions affecting the health of Europeans at local, national and international levels; and

put in place appropriate responses to deal with demographic changes and their health impacts.

The health governance element will provide a mechanism for holding decision-makers such as WHO and governments at European, national and local levels accountable, a lever for public health advocates to push for policy changes within countries, and a platform upon which to engage with the international community. The policy is currently being developed through a process of debate, discussion and consultation that is being directed by a focus on identifying appropriate interventions and opportunities to improve health and well-being, meet the challenges of the next decade, accelerate actions to reduce inequalities, develop mechanisms for partnership working within a coherent policy framework and provide support for decision-makers. The main products to emerge from the process during 2011 and 2012 will be:

the Health 2020 policy document, which will present an action framework for national, European and international partners;

a major review of the nature and magnitude of health inequalities and social determinants of health within and across European countries based on

3 This and subsequent “briefings” in this report are based on oral presentations given at the meeting.

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products from the European Review of the Social Determinants of Health and the Health Divide;4

a study and report outlining major challenges and responses to governance for health in the 21st century; and

topic- and issue-specific companion documents and instruments, such as specific policy briefs and guidance from across the Region and internationally that are informed by best evidence and promising practice on reducing health inequities and promoting better health for all.

It is clear, therefore, that Health 2020 will provide a vehicle to facilitate and support actions that make health and health equity a priority in decision-making in Europe and will create enabling conditions for more effective public health policies and governance. A wide process of engagement, partnership and consultation is planned for 2011/2012 to strengthen the engagement of diverse stakeholders across (and outside) the public health community in shaping European health goals and priorities and in identifying and responding to emerging opportunities and challenges. Health 2020: building the evidence base Briefing: Piroska Östlin, WHO Regional Office for Europe; Margaret Whitehead, University of Liverpool, United Kingdom (England) Two major studies are informing the evidence base for Health 2020:

the European Review of Social Determinants and the Health Divide Governance for Health in the 21st Century.

A range of smaller studies is also underway, including a review of around 100 WHO resolutions relevant to Health 2020 which aims to consider the commitments taken by Member States and WHO with respect to the Health 2020 main policy drivers. The European Review of Social Determinants and the Health Divide aims to:

provide evidence on the nature and magnitude of health inequities across the European Region, particularly outside the European Union (EU);

synthesize evidence on the most promising policy options and interventions in diverse country contexts; and

investigate gaps in capacity and knowledge. The review covers eight thematic areas focusing on key social determinants of health, including early years, education and family, employment and working conditions, and social exclusion, disadvantage and vulnerability. Each of the thematic areas has a task group. There is also a number of crosscutting task groups looking at issues such as economics, governance and delivery issues, equity, equality and human rights, and measurement and targets. Each task group is led by

4 Other products from the Review include synthesis reports of policy options to reduce social inequities in health and tools and instruments for cross-sectoral and whole-of-government approaches.

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an established research expert in the field and attempts to focus on the entire European Region. Senior advisers have been appointed by the Regional Director. Many researchers are working with the task groups on data collection in collaboration with their own networks. Collaborating centres and partners are invited to approach the task groups for information on how they can contribute and share good practice. The “ill-health prevention and treatment” task group, co-led by Gauden Galea, offers many opportunities for engagement with the collaborating centres and partners. This group has a very challenging task in reviewing what works in ill-health prevention through an equity lens. One of the best ways of supporting the task group’s work (once it has developed some initial positions) may be to draw on the collaborating centres’ and partners’ collective wisdom and informed opinions to offer a “sounding board” for policy reflections, interventions and the potential effects of proposed strategies − collaborating centres and partners are encouraged to make contact with the group to review the options and opportunities. The remit of the review is very ambitious and very challenging. It looks at inequalities in health not only within countries, but also between countries. There may be an assumption that the causes of, and solutions for, inequalities within countries are the same as those between countries, but this is questionable. The review is nevertheless long overdue and is more extensive than those completed by, for instance, the EU, and it will be a very valuable addition to knowledge in this area. The Governance for Health in the 21st Century study is developing an overview of new governance arrangements for promoting and protecting health. The challenging task of implementing the policy recommendations from Health 2020 will require new governance arrangements: it is very much about relationships among governments, social institutions and citizens, and about processes for making decisions. The study aims to determine the characteristics of good governance and define the role of health ministries in this context. Discussion and actions It was suggested that there are many similarities between Health 2020 and the Health in all policies framework. Chris Brown agreed, and said that the study currently underway in Europe on progress in implementing Health in all policies will inform the development of Health 2020. The adoption of a whole-system perspective in tackling health challenges also represents common ground with Health in all policies. Partners are looking to WHO for clarity and leadership on the Health 2020 issue, it was suggested. Chris Brown explained that it was explicit within the policy development process that WHO is re-evaluating how it can work better in this environment, brokering and supporting partnerships and recognizing that “leading” does not mean “controlling”. It was suggested that the collaborating centres and partners review the list of task groups for the European Review of Social Determinants and the Health Divide. If they are aware of any innovative research work in particular areas, they should

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inform WHO (Vivian Barnekow and Piroska Östlin), who will then distribute the information to the appropriate task group leaders. Due to the short time frames currently in place, it was not considered appropriate for collaborating centres and partners to develop specific papers for the task groups. However, their contribution in highlighting appropriate research work could be invaluable. Greater detail on the specific focus of the task groups would help collaborating centres and partners in identifying appropriate work. For instance, if the work on ill-health prevention being carried out as part of the process is going to have an impact, it will need to tease out how it can be taken forward through social policy. This “teasing-out” process can be done through, for example, case studies, literature reviews and key informant interviews, and the collaborating centres and partners are invited to contribute. In return, the task groups could be asked to distribute their emerging findings and ideas to the collaborating centres and partners as they become developed to enable them to take on the “sounding board” role suggested. The group confirmed that they were happy to be contacted by WHO to support the task group processes and to provide WHO with information that might be helpful to the task groups. There was a request that the potential political impact of the research studies be considered prior to release of their findings, taking into account potential political ramifications in different countries and regions. Advanced copies of final reports to government can be helpful in enabling them to prepare responses: this process is carried out at the launch of the Health Behaviour in School-aged Children (HBSC) international reports every four years.

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Item 2. European noncommunicable diseases action plan Briefing: Gauden Galea, WHO Regional Office for Europe The challenge for the noncommunicable diseases (NCD) action plan is to define actions now that will be seen to have made a difference in five years’ time. This means a process of selection on key high-impact actions is necessary, focusing on specific actions for the Regional Office and Member States on the risks and burden of NCD. The work will be taken forward in partnership across health systems and public health, with integrated surveillance systems being a necessary component. Understandings of social gradients and their causative impact on NCDs have grown, and inequities in some societies are now so strong that a high-risk approach targeting specific clusters of social disadvantage might be a sensible approach for the NCD action plan. It is important to understand the increasing presence of the private sector into the field of public health, with a concomitant increase in the influence of the private sector on the risk of NCD. This reflects the complexity of actors and stakeholders with which public health must contend. There are four lines of action. 1. Planning and oversight There needs to be a business plan that sets out key targets and outcomes, backed by investment to work across sectors and strong public health approaches. 2. Health in all policies The most cost-effective interventions for public health are fiscal interventions focusing on increasing the price of tobacco and alcohol. These interventions are underused in Europe. WHO has a mandate to regulate marketing of products, particularly of unhealthy foods to children and young people. Cross-sectoral working at regional level that engages with the private sector will be needed to secure reductions in salt, transfats and saturated fats in food products, aiming to ensure joint action across public and private actors. Experience gained in Europe on transport systems should be used to lever countries and municipalities to promote incidental physical activity among their populations. 3. Individual and community level WHO collaborating centres in health promotion and partners can be very helpful in defining what actions will be needed to increase health literacy at individual and community level and to promote community empowerment. Advice and suggestions are invited. 4. Secondary prevention Strong health systems and human and other resources are necessary to support secondary prevention measures, with health insurance schemes that provide access for disadvantaged communities. Two areas – cardiometabolic risk assessment and management (ranging from brief interventions to complicated risk assessments and

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management guidelines) and screening for particular cancers, such as cervical cancer – are suggested as the focus. The aim is to complete the NCD action plan by September 2011 and to seek approval at the WHO Regional Committee. Discussion and actions Achieving clarity on the objectives for the NCD action plan is crucial, it was suggested. This would equip advocates to use time with decision-makers to influence their actions in a positive direction. It short, it means defining the “what” of implementation before the “how”. The importance of the health sector explaining how it can support other sectors to achieve their objectives was emphasized. It was suggested that recent economic work shows that health promotion does not lead to reductions in cost in the health sector, but that it does have benefits in other sectors – this point needs to be stressed and should be reflected in the action plan (and in Health 2020). There is a need to look at NCDs such as heart disease, diabetes and cancer as a group rather than separately, it was stated, as so much of the morbidity associated with these conditions comes from common causes such as obesity, poor diet and lack of physical activity. The issue of whether regulation of the commercial sector is more effective than cooperation was raised. In several countries, large food and alcohol companies are influencing governments to relax regulation in favour of a more cooperative approach. It was suggested that both approaches are needed, but there is currently a real threat to the regulation of industries. Examples were nevertheless cited of multinational commercial companies taking forward very useful projects that aim to promote health, specifically in relation to children’s mental health. A question was asked on where health promotion sits within the NCD action plan. There was a danger that because the epidemic of NCD was so large and required so much resource to manage, attention on the causative factors could be dissipated. It was suggested that work should be done to create a public demand for health promotion based on wider understanding of its impact: this could be taken forward under the “individual and community level” set of actions. Empowering communities to demand greater action on health promotion would have a significant effect on political thinking and may also have an impact on commercial companies’ thinking about the need to make their products more healthy. It was accepted, however, that multinational companies often make improvements only on a “uninational” rather than a global basis – the demand for change must be taken forward country by country. In addition, it was felt that the action plan could focus more on the concept of health and how individuals and communities can develop capabilities to live healthy lives. This is already reflected in the “empowerment” sections of the draft, but practical ideas on how the action plan can convey this further are invited. Some concerns around the notion of “community empowerment” were expressed, however, in that further community empowerment may entice some governments to opt out of their

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responsibility for promoting community health. It cannot all be left to communities, it was stressed. Public health has not been effective at “being political”, it was felt, and this had to change. Different government departments and sectors need to be shown how health is an asset that can support them. In terms of persuading a minister to act, research should highlight what actions need to be taken to have an impact and should clearly demonstrate how it can support the minister in building a strong case that will withstand political scrutiny. WHO can support ministers to overcome the unintended consequences of public health actions, such as the potential for policies on minimum pricing for alcohol breaching European law. It would be important for WHO to consider how the language in the NCD action plan (and Health 2020) can ensure that the underpinning values of partnerships and inclusion are prominent. Some of the more complicated passages in the NCD draft text could probably be simplified to increase understanding and access. It was suggested that it was acceptable for the NCD action plan to refer to individuals as “patients”; this may help to open access to those in the health community who are sceptical about the influence of social determinants of health and the effect of health promotion and, indeed, to members of the public who see themselves as “patients” from time to time. “Patients” are still members of their communities, and the term should not be dismissed in an effort to increase inclusion. There are risks with using the word in terms of labelling, especially in relation to NCDs and its impact on areas such as employment prospects, but it was suggested that in the right context, WHO should not be reticent about using the word “patients”. The main roles for collaborating centres and partners in relation to the NCD action plan are to influence its content initially, then to support its implementation at national level. The collaborating centres and partners have significant potential to contribute to the NCD action plan through the provision of data, advice, good practice examples and capacity building. WHO would like to see the collaborating centres and partners looking carefully at the action plan that emerges and identify areas where they can work in partnership with each other on implementation. They should see the action plan as an arena, or “menu”, from which they can select areas of highest interest and work on them. The NCD action plan is being based on the very comprehensive NCD strategy published in 2006. It was conceded that an attempt to commit everything that was in the strategy to implementation through the action plan would result in failure. The action plan will consequently tend to focus on actions that can be measured and monitored, which may sway it towards medical interventions. Countries can nevertheless be urged to go beyond that focus. The original NCD strategy, it was stressed, contains much on social determinants and health promotion that countries can engage with – the message that the action plan will be “just a starting point” for actions needs to be reinforced, with countries being encouraged to develop a more comprehensive approach. Gauden Galea responded to a number of points. He explained that the action plan would not be in a position to eliminate the root causes of NCD, important thought

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they are. The NCD action plan will rely on Health 2020 to tackle these issues – if Health 2020 is unsuccessful in this endeavour, he suggested, the impact of the NCD action plan will be limited. Good articulation between the two is therefore very important. Addressing common risk factors is nevertheless a powerful way of taking individual diseases and conditions out of their “silos”, Dr Galea said. Poverty seems to be a common linking factor across these conditions, so it may be sensible in future not only to screen for physiological indicators of disease progression, but also to perform means tests to ensure vulnerable people have access to appropriate prevention and management services. Dr Galea suggested that there are many ways in which health and research bodies can work with the private sector without recourse to the granting and acceptance of resources. These range from workplace wellness programmes to product reformulation and many other examples that do not involve direct influence on public health policy. A paper prepared by Dr Galea outlining his summary of the suggestions raised by the participants regarding collaboration with the collaborating centres and partners around the NCD action plan was presented: this is reproduced at Annex 2. Collaborating centres and partners were invited to consider these ideas over the coming weeks.

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Item 3. Open session Discussions revolved around how collaborating centres and partners can make contributions to supporting Health 2020 and the NCD action plan. The documents should reflect the fact that regions have a great deal of responsibility for health in countries and should not over-focus on international, national and local levels, it was suggested. There are dozens of regional networks active in this field. WHO should not bind itself to national level – the Healthy Cities approach, for example, has been very successful. It was pointed out that there will be a formal debate on Health 2020 at the 2011 Regions for Health Network conference. WHO is very keen to work more closely at regional level, although it must be noted that WHO’s formal relationships are with national governments. It is for the Member States to decide how WHO is organized, but there may be a need for flexibility in future, with regional government structures that have significant autonomy in relation to health issues featuring increasingly in many European countries, including Germany, Spain and the United Kingdom. Questions were asked about how collaborating centres can reorient their workplans (developed at national level) to reflect changed priorities at European level through Health 2020 and the NCD action plan. It was felt that with the agreement of national governments, this should be possible. It should be noted, however, that many collaborating centres and partners have broadly formulated objectives that provide room for flexibility in what work is taken forward. It is considered important that collaborating centres do not drop their important work in areas such as child and adolescent health to focus on Health 2020 and NCD action plan work. It was also suggested that collaborating centres should not be too adventurous in changing their workplans without consultation with WHO, either the Regional Office or WHO headquarters. It was also suggested that there is no need for collaborating centres to readjust their workplans – everything they are doing is relevant to Health 2020. It is more about WHO supporting collaborating centres and partners to maximize their impact in informing how Health 2020 develops. Semantics are important, and it was noted that the expression “high-level” was used in association with the First Meeting of the European Health Policy Forum for High-level Government Officials held in Andorra in March 2011. Does this imply that people functioning under this level are necessarily “low-level”, it was asked? This kind of description is embedded in institutions across the globe, it was suggested, but if the aim is to develop truly collaborative work that is fully inclusive and democratic, it is surely inappropriate to suggest people such as civil society actors, academics and regional bodies are not functioning at the same level as senior government officials. Change in the language used needs to be part of the change process that is driving Health 2020 and the NCD action plan, it was stated. Current use of language excludes many actors who have significant contributions to make. It was confirmed that this message would be taken back to inform internal debates within WHO.

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Item 4. EU 2020 Briefing: Clive Needle, EuroHealthNet EuroHealthNet is not a formal collaborating centre, but considers itself a collaborating partner of WHO. It has been active for 15 years and works on a range of policies and projects to bring a wide group of stakeholders together to change the EU for the better. All collaborating centres and partners are eligible to join. EuroHealthNet’s major project at the moment is funded by the EU social programme: the PROGRESS Framework is about building bridges between health and social communities in follow up to the “solidarity in health” policy. There has been significant political change in Europe, with the economic crisis playing a big part in determining policy priorities. EU 2020 priorities are now dominant, based on government cooperation with the private sector and high-technology approaches. The European Community (EC) and national governments have agreed flagship policies around “smart growth, sustainable growth and inclusive growth”, with “innovation”, “competitiveness” and “targets” being key concepts. While health may not be explicitly detailed, the Health in all policies approach means it is very much to the fore. The EU budget is changing accordingly, with 45% now being assigned to “cohesion and competitiveness for growth and employment”. Only a tiny proportion is assigned to health. The warning is that while a minimal programme for risk and threat protection is required by the EU (Lisbon)Treaty,5 this will not necessarily include health improvement, health promotion and NCDs: unless there is strong evidence and advocacy in its favour, there will not be a public health action programme after 2014. Health needs to be active now in seeking access to resource from various strands of the EU budget. There is a real risk that there may be no explicit health research funding in the next framework programme. The EC is warning that unless the case for health funding can be made over the next year, it will be spent in the growth and competitiveness arena: decisions on the 2014 budget are being taken now – waiting until 2013 to advocate for health will be too late. The argument that the EU has no place in health is becoming more strident, with health being highlighted health as an area for budget cuts. It is also significant that the rules on securing funding are being simplified to encourage private sector partners to take part. The Together for health strategy, published in 2008, is no longer considered viable by EC officials. Their focus now is on the flagship target of increasing healthy life years by two years over the next decade. A steering group consisting of public−private partners is being formed to progress this agenda, with a high technological focus likely. There is no health promotion advocate currently involved. The language has also changed – there is no longer talk of “determinants” of health: instead, a focus on “risk factors” is emerging, which many people in health promotion consider a regressive step. This emphasizes how important it is for WHO to get Health 2020 right to direct work with the EC and keep the Health in all policies approach alive. 5 Article 168 of the EU (Lisbon) Treaty requires protection of human health by the EC, but health improvement and well-being are only general responsibilities, rather than specific.

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There are, however, potential opportunities for health promotion and Health in all policies approaches, particularly in areas such as youth unemployment and equalities work. These approaches are also relevant to the new platform against poverty in the EU. It is important to note, however, that this will involve working with a range of directorates. EuroHealthNet is reflecting this in its activity across health, social policy and research agendas and is increasingly working with a wide range of directorates, including:

education, to encourage the inclusion of early child development and youth health;

environment, to offset the loss of the health and environment action plan and to progress work on climate change;

transport, to encourage progress on developing a road safety strategy and encouraging a cross-sectoral approach; and

food, to progress nutrition profiles within the food debate. Structural funds for health amount to €5 billion, but €330 billion is available from other structural funds for social and economic developments in areas that have an enormous impact on the determinants of health, such as employment. Health actors are largely excluded from discussions on these funds in some countries, so they need to be ready to lobby for access to the discussions. The EU 2020 agenda is therefore one in which flagship policies have been identified. The health promotion community needs to define what indicators it would like to see applied to these policies and how accountability can be assured. Public−private partnerships are being encouraged, but what is the evidence to support them? Can the health promotion community set conditions for working with them, or do they simply accept them as a fact of life? More may be done at European level to understand social and health inequities, but it will be down to the health promotion community to act, with Health 2020 playing a leading role. Health 2020 can pull priorities together, but who will pay for it? It may not be the EC after 2014. Decisions have to be made on whether the health promotion community complies with the Euro 2020 agenda or advocates for an alternative approach. Discussion and actions WHO senior officials met the EC recently and agreed to collaborate on the following areas at country level: health security; health innovation; health systems; health information; and health inequality. Deepening and widening health inequalities were recognized as an indicator of the failure of global health policy, and a clear decision was taken to engage with the European Review of Social Determinants and the Health Divide. The EC was interested in hearing how WHO and its partners can help to develop policy guidance, and some strategic partnerships on this are envisaged.

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Item 5. Collaborating centres’ and partners’ main activities, opportunities and challenges Netherlands Institute for Health Promotion: WHO collaborating centre for school health promotion The focus of the Netherlands Institute for Health Promotion (NIGZ) is on implementation rather than research. NIGZ hosts the secretariat for the Schools for Health in Europe (SHE) network, which has 43 Member States. This is a very active network for building and exchanging knowledge and building capacity in Member States. SHE follows core values of equity, sustainability, inclusion, empowerment and democracy, which mirrors the core values of Health 2020 and the NCD action plan. The network recognizes that health is a means to an end and works closely with schools to promote the realization that pupils with better health are likely to perform better academically. In the Netherlands, this manifests in the network receiving more funding support from the education ministry than from the health ministry. NIGZ follows health promotion principles and promotes an integrated approach that emphasizes health as an asset that will benefit society. It recognizes that health is a dynamic concept that changes according to the environment and works to deconstruct complicated concepts around health to create tangible actions that promote alliance-building outside the health sector. These include actions in relation to school health promotion, health literacy and e-health promotion. NIGZ is currently spearheading an alliance on health literacy with more than 60 organizations and is working with commercial companies on e-health projects. International networking is very important to NIGZ, particularly in relation to influencing health policy within the Netherlands. Federal Centre for Health Education, Germany: WHO collaborating centre for sexual and reproductive health The Federal Centre for Health Education (BZgA) is a governmental organization within the portfolio of the federal ministry of health. It has responsibility for:

development of principles and guidelines on the contents and methods of health promotion and health education;

coordination; planning, implementation and evaluation of prevention campaigns; development and implementation of training programmes and instruments;

and international cooperation (with, for example WHO and the EU).

At national level, BZgA hosts the national cooperation network for health promotion with socially disadvantaged people, which has developed a directory of good practice in Germany that has some 1700 projects. It also holds an annual conference for around 2000 people to showcase what is happening in public health in Germany.

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Focal points at regional level are key to developing cooperation, creating networks and identifying good practice at federal state (länder) level. Internationally, BzgA has been working with EuroHealthNet since the late 1990s, including work on the Closing the Gap project. It is currently involved in an EU project on joint action on health inequalities, a project on Health in all policies (“Crossing bridges”) and a research project looking at the social gradient. Since 2007, it has been involved in an intersectoral project on early prevention of child neglect and abuse that focuses on children up to three years of age who live in stressful family situations. This project aims to build parental skills and improve the circumstances of families in these situations. School of Public Health, University of Bielefeld, Germany: WHO collaborating centre for child and adolescent health promotion This is a research institute dealing with child and adolescent health promotion. Its empirical basis is the HBSC study, and the focus tends to be on epidemiological research. The university’s public health institute has been involved in much work on social inequalities in health, but this is not a topic of huge interest in Germany. The focus therefore changed last year to look at gender as a key determinant of health, reflecting the recognition that gender influences health in many ways and interacts with other social determinants. Work is underway in collaboration with the BZgA to identify target populations for interventions and to shape health promotion interventions to suit. The work is exploring the evidence to identify what works well and for which groups. Attempts are also being made to build a knowledge transfer centre to stimulate discussion on appropriate ways forward. This work has only just begun: a web site has been built and brief factsheets are being developed to promote discussion. Education programmes will also be developed to support people to put evidence into practice. Department of Public Health and Policy, University of Liverpool, United Kingdom (England): WHO collaborating centre for policy research on social determinants of health The department is now in its second redesignation as a collaborating centre. It is active in a range of ways to support WHO to:

look at the impact of non-health policies on health and health inequalities; monitor policies and strategies to tackle the social determinants of inequalities

in health; and build capacity in monitoring and evaluating strategies to address social

determinants of inequalities in health. In doing this, it works very closely with the WHO European Office for Investment for Health and Development in Venice, Italy. England faces a number of challenges in relation to the social determinants of health, but the two key challenges are:

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the differential impact of economic and welfare policy changes in response to the current financial crisis; and

the effects on equity of access of proposed reforms to the National Health Service (NHS).

There is great concern about the effects of economic and welfare policy changes on people in disadvantaged areas. Evidence developed by the department shows that local authority budget cuts are largest in the most deprived areas. It demonstrates the imperative of being able to measure, record and disseminate information on the impacts. NHS reforms are also causing anxiety. Some misinformation is being used to support the case for radical reform of the NHS, with crosscountry analyses being used inappropriately to suggest that the NHS is in need of reform. The department therefore has a key role in entering the debate and disseminating accurate information and evidence. Department of Prevention and Innovation, North Rhine−Westphalia Institute of Health and Work, Germany: WHO collaborating centre for regional health policy and public health Social determinants and inequity issues have been key areas of regional health policy in North Rhine−Westphalia for over a decade. The institute has been active in producing analyses of status and trends and providing online information. Social determinants and inequities are integrated into the institute’s activities, such as developing health targets with the ministry of health, providing prevention programmes and producing a project database at state level that articulates with the federal database. The institute also focuses on health innovations, predicting the health situation in North Rhine−Westphalia and undertaking “what if ...” types of analyses. This part of the institute also monitors the introduction of health innovations within the state and tries to understand what their impacts might be. Most projects are funded externally, with the EC being a major supporter. Health in all policies is a key driver of the institute’s work with employment, environment, children and youth, housing and planning and development sectors. Specific activities include promotion of physical activity, looking at links between health and unemployment, urban and rural health and generally exploring opportunities to make health an issue in local and regional planning. The institute is currently involved in the EC Directorate-General for Health and Consumers (DG-SANCO) co-funded RAPID project, preparing a health impact assessment of the policies underpinning the project. It has very limited resources for extra activities but holds regular regional conferences and workshops that may be of interest beyond the state. Reports of these events and other projects are published in German, but work is underway to develop a bilingual section of the web site that will include at least abstracts or summaries of projects in English. The ability to receive critical and constructive responses to the institute’s work has been hampered by the language barrier, but this will hopefully soon dissipate.

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National University of Ireland, Galway: WHO collaborating centre for health promotion research The university was designated a collaborating centre in 2009 through WHO headquarters. The aim is to build health promotion capacity through the generation and application of health promotion research into practice and policy. This involves:

generating knowledge through the conduct of original health promotion research;

developing methodological approaches to health promotion research; undertaking the synthesis and review of research to inform policy and practice

in health promotion; evaluating the adoption and implementation of health promotion interventions

in collaboration with practitioners and policy-makers; disseminating the health promotion knowledge and evidence base to target

audiences, including policy-makers, practitioners and members of the public; and

collaborating with national and international partners on the advancement of health promotion research, policy and practice.

Five work areas have been agreed, with the focus being wider than the European Region. Activity 1 focuses on benchmarking implementation of health promotion, specifically the Bangkok Charter for Health Promotion in a Globalized World and the Nairobi Call to Action, through capacity building and workforce development. Work here has focused on developing a set of global core competencies for health promotion and performing a scoping study of low- and middle-income countries around capacity for health promotion and related priority needs. A collaborative project with 22 partners has been launched to promote the global competencies within the European context, and a handbook has been published. Activity 2 also focuses on building capacity, this time in health promotion research through training and education. Work has been taken forward with institutes in Bergen, Norway and Vienna, Austria to benchmark processes around education and training. Activities 3−5 are about building the evidence base to inform practice and policy in three areas: health promotion with young people and schools (linking with the HBSC study and feeding into the development of national indicators), mental health promotion (with a particular focus on policy development and the place of mental health promotion within a wider well-being agenda) and health promotion in the workplace (focusing particularly on the public sector). The university is also working with the health ministry in Ireland on developing a new public health policy and the European Centre for Disease Prevention and Control on evidence around health literacy. National Institute for Health and Welfare, Finland: WHO collaborating centre for promotion of equity in health The institute is currently going through a process of redesignation as a collaborating centre to enable it to focus more on social determinants of health. This will mean a

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comprehensive reorientation of activities, including the development of an updated workplan. The institute currently has around 1400 people working on research and development in social and health policy, promotion and prevention. It is the national authority for maintaining registers and statistics in these areas under the ministry of social affairs and health. The institute has been closely involved in the development and interpretation of the NCD strategies at global and European levels. An annual seminar on prevention and control of NCD is held to educate prevention professionals from around the world and promote implementation of the strategies. These are held by a second collaborating centre in the institute (on NCD). The institute has a national project looking at implementing the recommendations of the Marmot Review, and this will form part of the new workplan of the redesignated collaborating centre. The ministry of social affairs and health is the formal collaborator with the EU 2020 and Health 2020 initiatives, but the institute is active in supporting work in these areas. A new strategy, Socially sustainable Finland 2020, is currently being developed. It has three main elements: equality, inclusion, and promotion of health and functional ability for everyone. Social sustainability is the strategy’s driving force, reducing differences between health and welfare and improving the position of the most vulnerable groups. The emphasis is on health and social welfare in all policies, sustainable funding of social protection and more customer-focused services. There is also a strong focus on environment. NHS Health Scotland (United Kingdom (Scotland)): WHO collaborating centre for health promotion and public health development A significant element of the funding available to the collaborating centre focuses on supporting the HBSC study: the funding is £250 000 per year, which represents around 90% of the HBSC international coordinating centre’s funding. The current contract finishes in September 2012, and ideas for ongoing funding support are welcome. Much of NHS Health Scotland’s collaborating centre’s work is outward facing, in that it focuses on initiatives outside Scotland. The centre has recently been working with health and education ministries in Albania, reviewing school health services and encouraging multidisciplinary working. It also produces a variety of papers around human resources, public health science and topic-specific issues, promoting evidence-based and evidence-informed processes. The WHO European strategy for child and adolescent health and development supports the national performance framework in Scotland, particularly around the “early years” framework. It is about improving life opportunities for children and young people, and the HBSC national report for Scotland contributes to this. While there is an ambition to see even greater progress through HBSC study results, it is clear that improvements in health behaviours are being seen over time among children and adolescents in Scotland.

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Scotland adopts a whole-of-government approach to policy development. The Scottish Government has stated an ambition to create a Scotland that is wealthier and fairer, smarter, healthier, safer and stronger, and greener, and all government activity and public sector funding need to demonstrate compliance with these ambitions. All activity within the collaborating centre and the wider NHS Health Scotland organization contributes to meeting these ambitions. NHS Health Scotland is due to go through the redesignation process by October 2011. Observatory of Women’s Health, Ministry of Health, Social Policy and Equality, Spain (not currently a WHO collaborating centre) The observatory has strong collaboration with WHO on gender issues and health. It is part of the ministry and is responsible for activity in three main areas:

promoting a gender approach within information systems, ensuring sex-disaggregated data are published and that changes are introduced to national surveys to allow a gender analysis to inform policy development;

promoting gender mainstreaming in health strategies, working with the ministry in areas such as strategies for cardiovascular disease and mental health that have important gender associations, determining gender-specific analyses, objectives and indicators; and

supporting good practice at local level to reduce social inequalities including, but not exclusive to, gender.

The observatory believes that these kinds of activity can make a significant contribution to the work WHO is taking forward with the collaborating centres. The Health Behaviour in School-aged Children study HBSC is coordinated from the Child and Adolescent Health Research Unit (CAHRU) at the University of Edinburgh, United Kingdom (Scotland). The work is principally funded through the WHO collaborating centre for health promotion and public health development at NHS Health Scotland, so there are very strong links with the collaborating centre. The study now has 43 countries in Europe and North America. It is in continuous dialogue with WHO and is contributing to Health 2020 through its international report, published every four years. The current report is being developed from data collected in 2009/2010 in 40 countries. It will have a strong inequalities approach, looking at age, gender, family affluence and geography. Capacity building is also an important aspect of the HBSC work: the study operates in six geographic zones, each of which has a HBSC lead who supports new countries to become involved. HBSC has always had a social determinants approach and has been active in informing a wide range of strategies and policies. It is also enthusiastic about developing research methods and knowledge transfer exchange through its three main working groups: a scientific development group, a methodology development group and a policy development group. Efforts to translate HBSC findings into readily

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accessible information and materials that policy-makers and others can use to inform their activity are ongoing. HBSC works closely with other centres in Europe, such as the data management centre in Bergen, Norway, the Ludwig Bolzmann Institute in Vienna, Austria and the National Institute for Health and Clinical Excellence in England. National case studies from HBSC have been used in three WHO/HBSC forums, supported by the WHO European Office for Investment for Health and Development in Venice, Italy: these have focused on healthy eating and physical activity, mental health, and environmental impacts on the health of young people. The case studies feed into the forums and channel into the development of international policy. The study has now been active for 30 years. A review is currently underway and the collaborating centres’ and partners’ group can be very influential in determining the shape of the study over the next decade. For instance, questions are being asked about whether the study should reach out to other age groups: there is a great demand for data on children aged 7−10 and young people aged 16−24, neither of whom are covered by the study. HBSC is interested in developing new methods to reach these groups, and also hard-to-reach groups for whom there is currently poor data but who probably suffer most from health inequalities. HBSC data have been used in the UNICEF Report Card 9, Organisation of Economic Co-operation and Development (OECD) reports and a series on adolescent health for The Lancet, so the data are being disseminated widely. Nationally, one of the key aspirations is to stimulate better use of national data. The CAHRU has worked hard to think of new ways of presenting HBSC data to engage with policy-makers and practitioners in Scotland and influence national programmes. Discussion and actions It was emphasized that despite the impression that may arise from the host countries of collaborating centres and partners attending the meeting, it is not a requirement for a collaborating centre to be hosted by an EU country. There is no doubt, however, that building capacity, knowledge and research tends to be a western European-dominated activity. There are several reasons for this, it was suggested, including language barriers, but there is a strong ambition to extend collaborating centres beyond the EU and western Europe. Participants were reminded that not all collaborating centres were represented at the meeting. The WHO collaborating centre for capacity building on cross-sectoral investment for health is based at the Centre for Health and Development, Murska Sobota, Slovenia6 and works exclusively in the Balkans, and the Kosice Institute for Society and Health in Slovakia, which will soon be designated as a collaborating centre, will focus on monitoring and analysis of health inequalities in central and eastern Europe. It was felt to be important to establish if any key collaborating centres had been omitted from the group. There needs to be some agreement, however, about how far

6 Tatjana Buzeti from this collaborating centre was scheduled to attend the meeting but was unable to do so for unavoidable reasons.

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the group wishes to spread its net, particularly in relation to collaborating centres that do not specifically focus on social determinants of health but which nevertheless do important work in related areas, such as water quality and urban development. Comments were made regarding the mechanics through which the collaborating centres report back to WHO on their workplans. There were concerns about the technicalities of submitting reports and the electronic format in which they must be presented. However, feedback and relationships with WHO were reported as being very good, particularly between the centres and their contacts at WHO. It was also pointed out that information can be disseminated by other means apart from the WHO technical system. There are clearly opportunities for individual collaborating centres to work more closely with each other, highlighting understandings of each others’ interests, activities and workplans, and general agreement to take this forward on an individual basis was reached. Partners who were not currently collaborating centres also expressed enthusiasm to work closer with the collaborating centres. The issue of mechanisms for collaboration among the collaborating centres and partners was raised. There are opportunities for individual centres to comment directly on documents such as Health 2020 and the NCD action plan, for instance, but the establishment of this collaborating centres’ and partners’ group offers the opportunity for combined responses to emerge. In addition to this kind of meeting, there is also perhaps a need to consider ongoing mechanisms for communication among the centres on selected strategic areas: it is important that the communication does not end when this meeting ends, it was stated. It was confirmed that WHO is very keen to engage more actively with the expertise and experience in the collaborating centres and that held by partners, although the exact mechanisms need to be identified. It was suggested that WHO and the collaborating centres and partners consider what would be most suitable for them on an ongoing basis. Methods of communicating and sharing information better were then explored. It was suggested that a web site be developed to provide a password-protected platform for information sharing among the collaborating centres. NIGZ potentially has the capacity to host this platform through existing resources. It would be important to organize the web site according to themes so that collaborating centres could access relevant information quickly, it was suggested. As a starting point, the organizations represented at the meeting would be included, but others would be added over time. Collaborating centres and partners would benefit from information about key technical contacts at WHO for specific areas of activity to enable them to make contact direct. There was agreement that the group would like to meet again on at least one occasion. An offer to host a second meeting in Germany (Cologne or Berlin) was made by BZgA.

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Item 6. Agreed action points The key action points to arise from the discussions were:

review technical capacity and mechanics for collaborating centres submitting reports to WHO;

explore the possibility of developing a password-protected online platform on the NIGZ web site for information sharing;

review procedures for collaborating centres and partners submitting information and appropriate research to WHO for sharing with the European Review of Social Determinants and the Health Divide task groups;

confirmation of NHS Health Scotland WHO collaborating centre for health promotion and public health development as convenor of the WHO collaborating centre and partner network; and

organize a second meeting in February 2012 in Germany.

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Annex 1. List of participants Jakobus Koot WHO collaborating centre for school health promotion Chief Executive Officer, Youth Department Netherlands Institute for Health Promotion and Disease Prevention PO Box 500 − 3440 AM 3440 AM The Netherlands Phone: ++31348437601 E-mail: jkoot@nigz.nl Margaret Whitehead WHO collaborating centre for policy research on social determinants of health Research Group on Social Context and Consequences of Ill Health Department of Public Health and Policy University of Liverpool Whelan Building, Liverpool L69 3GB United Kingdom Phone: +441517945280 E-mail: mmw@liverpool.ac.uk Tatjana Buzeti7 WHO collaborating centre for capacity building in cross-sectoral investment for health Director, Centre for Health and Development Murska Sobota Arhitekta Novaka 2b SI-90000 Pomurje Murska Sobota Slovenia Phone: +38641797508 E-mail: tatjana.buzeti@czr.si Helene Reemann WHO collaborating centre for sexual and reproductive health Head of International Unit Federal Centre for Health Education (BzgA) Ostmerheimer Str. 220−D-51109 D-51109 Cologne Germany Phone: +492218992000 E-mail: Helene.Reemann@bzga.de

7 Unable to attend meeting.

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Candace Currie WHO collaborative cross-national study: Health Behaviour in School-aged Children (HBSC) International Coordinator of the Health Behaviour in School-aged Children study Director, Child and Adolescent Health Research Unit (CAHRU) The Moray House School of Education The University of Edinburgh St Leonard's Land Holyrood Road Edinburgh EH8 8AQ United Kingdom Phone: +441316516258 E-mail: candace.currie@ed.ac.uk Clive Needle EuroHealthNet Director Rue de la loi, 67 B-1040 Brussels Belgium Phone: +3222350320 E-mail: info@eurohealthnet.eu Rainer Fehr WHO collaborating centre for regional health policy and public health Department of Prevention and Innovation NRW Institute of Health and Work (LIGA−NRW) Westerfeldstraße 35−37 North Rhine−Westphalia Bielefeld D-33611 Germany Phone: +495218007253 E-mail: rainer.fehr@liga.nrw.de Concha Colomer Revuelta Observatory of Women’s Health Deputy Director of the Office of Health Planning and Quality General Agency of Quality of Health System Ministry of Health, Social Policy and Equity Paseo del Prado 18−20 E-28071 Madrid Spain Phone: +34915961559 E-mail: ccolomer@msps.es

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Petra Kolip WHO collaborating centre for child and adolescent health promotion Bielefeld School of Public Health (BISPH) University of Bielefeld Universitätstraße, 25 D-33615 Bielefeld Germany Phone: +495211063834 E-mail: petra.kolip@uni- bielefeld.de Margaret Barry WHO collaborating centre for health promotion research Health Promotion Research Centre Department of Health Promotion National University of Ireland, Galway 16 Distillery Road Galway Ireland Phone: +353091493348 E-mail: margaret.barry@nuigal way.ie Roza Adany University of Debrecen Dean Faculty of Public Health 4012 Debrecen, Pf. 9 Hungary Phone: +3652417267 E-mail: adany@med.unideb.hu Sakari Karvonen WHO collaborating centre for promotion of equity in health National Institute for Health and Welfare Director of Department, Adjunct Professor Department of Social and Health Policy and Economics PO Box 30 FI-00271 Helsinki Finland Phone: +358206107449 E-mail: sakari.karvonen@thl.fi

David L Pattison WHO collaborating centre for health promotion and public health development NHS Health Scotland Woodburn House Canaan Lane Edinburgh EH104SG United Kingdom Phone: +441315365559 E-mail: david.pattison@nhs.net

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Rapporteur

Alex Mathieson Freelance Writer and Editor 15 Riselaw Terrace Edinburgh EH10 6HW United Kingdom Phone : +441314783339 E-mail: alex.mathieson@blueyonder.co.uk

World Health Organization Regional Office for Europe Gauden Galea Director Division of Noncommunicable Diseases and Health Promotion Scherfigsvej 8 2100 Copenhagen Denmark E-mail: gga@euro.who.int Piroska Ostlin Special Adviser Scherfigsvej 8 2100 Copenhagen Denmark Phone: +4523319487 E-mail: pio@euro.who.int Vivian Barnekow Programme Manager, Child and Adolescent Health and Development Division of Noncommunicable Diseases and Health Promotion Scherfigsvej 8 2100 Copenhagen Denmark Phone: +4539171410 E-mail: vbr@euro.who.int Christine Brown Programme Manager, Division of Country Health Systems WHO European Office for Investment for Health and Development San Marco 2847 30124 Venice Italy Phone: +390412793847 E-mail: chb@ihd.euro.who.int

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Annex 2. Summary of ideas for collaboration on the NCD action plan A menu for collaboration would include:

leadership in a defined area of evidence interpretation and deriving policy implications;

training and exchange opportunities in a defined area of NCD action; compilation of models of good practice in a database accessible across the

Region; development of policy briefs; and creation of opportunities for joint advocacy in support of the NCD action plan

and for joint resource mobilization.

Partner Current and potential actions

EuroHealthNet dissemination of NCD actions to partners convening of governmental and nongovernmental

organization (NGO) partners in support of action plan joint advocacy and consultation in the development of

Euro 2020 and in NCD reflection process of DG-SANCO in 2012

Netherlands Institute for Health Promotion and Disease Prevention WHO collaborating centre for school health promotion

school health education – link with teacher health e-health promotion – models and examples for NCD research and evidence backing for NCD action in

children and adolescents – marketing? Effect of fiscal interventions? Trends in behaviour? Protective factors?

Department of Public Health and Policy, University of Liverpool, United Kingdom (England) WHO collaborating centre for policy research in social determinants of health

analysis of social determinants of health implications of actions within the NCD action plan

Observatory of Women's Health, Spain

cervical cancer – monitoring, evidence, policy formulation, country support

advice on gender issues in NCD policy – review of national plans, capacity building

models of health promotion financing through sickness funds

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Partner Current and potential actions

North Rhine−Westphalia Institute of Health and Work, Germany WHO collaborating centre for regional health policy and public health

scenario building and impact assessment: cost of NCD? Scenarios for life years saved? Scenarios for levelling up inequities?

regional (subnational) health implementation of NCD action plan

specific action in areas of subnational policy and links to NCD: environment, children, housing, urban planning and design

National University of Ireland, Galway WHO collaborating centre for health promotion research

capacity building for health promotion reviews of health promotion actions in support of NCD

action plan clarification of concept and levels of “health literacy”

National Institute for Health and Welfare, Finland WHO collaborating centre for promotion of equity in health

direct contribution to the formulation of the NCD action plan (ongoing)

training and capacity building (ongoing)

NHS Health Scotland WHO collaborating centre for health promotion and public health development

support for HBSC until 2012 convenor of the WHO collaborating centre network compilation (database, learning house) of models of

good practice in Scotland and in the Region

WHO HBSC study thirty-year data series on behaviour of school-aged children

next report to focus on policy reflections of the data on social determinants of health outcomes and health behaviours

connection to Global Youth Tobacco Survey?